Summary: Mr B complained about a Hospital Trust’s decision to discharge his late father, Mr G, home from hospital in October 2020. He also complained about the community health and social care support provided to his father by a Community Trust and the Council. We did not find evidence of fault in the actions of the Community Trust. There was fault in the way the Hospital Trust and the Council dealt with Mr G’s discharge arrangements including how they considered the impact of the caring role on Mrs G, his wife. The Hospital Trust and the Council have agreed to our recommendations and will apologise to Mr B and Mrs G. They will also make a symbolic payment of £250 each to Mrs G to acknowledge the adverse impact the faults had on her.

The complaint

1. The complainant, who I shall refer to as Mr B, complains about his late father’s (Mr G) discharge from a hospital run by University Hospitals Dorset NHS Foundation Trust (the Hospital Trust) in October 2020. He says the Hospital Trust should not have discharged his father home when he was still suffering with a urinary tract infection (UTI) and needed hospital care and treatment. He says once his late father was in the community Dorset Healthcare University NHS Foundation Trust’s (the Community Trust) community nursing team and carers commissioned by Dorset Council (the Council) failed to provide good care and support in relation to the UTI and catheter and this caused his father’s condition to worsen between 8 – 19 October resulting in readmission to hospital.
2. Mr B says when his father was readmitted to hospital the Hospital Trust placed his father on a ward with patients who had tested positive for the virus known as COVID-19 and this resulted in him contracting the virus. The complainant says the faults impacted on his mother’s (Mrs G) needs as a carer and caused him and his mother avoidable distress because the faults led to the death of his father. To put things right Mr B says the authorities should learn from the faults and improve. He also wants the organisations to apologise to him and his mother and pay a financial remedy.

Back to top

The Ombudsmen’s role and powers

3. The Ombudsmen have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
4. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
5. The Ombudsmen cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
6. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

7. I have considered:
• information provided by the complainant in writing and by telephone.
• information provided by the Council and the NHS Trust in response to my enquiries.
• the law and good practice guidance relevant to this complaint.
8. All parties had an opportunity to respond to a second draft of this decision. I considered the responses before reaching a final decision.

Back to top

What I found

Law and guidance relevant to this complaint

9. National guidance called “Hospital Discharge Service: Policy and Operating Model” published in August 2020 was in place for hospitals, councils, and social care providers in September 2020. The following are relevant points from that guidance.
• The Government provided extra funding to help cover the cost of post-discharge recovery and support services. This was for up to six weeks following discharge from hospital.
• Hospitals should use a “discharge to assess pathways model”. Pathway 1 was for people well enough for discharge from an acute hospital but still needed support to recover at home and able to return home with support from health and/or social care.
• Hospitals must transfer information “essential to the continued delivery of care and support” to social care services on discharge.
• “Health and care systems should ensure effective information sharing, and full and carefully documented assessments of need, to ensure care providers can deliver the care and support people require”.
• Individuals must be fully informed of the next steps.
• This guidance should be read alongside the National Institute for Health and Care Excellence (NICE) guideline NG27 “Transition between inpatient hospital settings and community or care home settings for adults with social care needs”.
10. NG27 says:
• discharge planning should start as soon as a person with complex needs is admitted to hospital;
• hospitals should keep people regularly updated about any changes to their plans for transfer from hospital; and
• hospitals should have discharge coordinators who are responsible for coordinating people’s discharge from hospital. Discharge coordinators are the central point of contact for health and social care practitioners, the person and their family during discharge planning.
11. NG27 says discharge coordinators should:
• be involved in all decisions about discharge planning;
• work with hospital- and community-based multidisciplinary teams and the patient to develop and agree a discharge plan;
• arrange follow-up care;
• discuss the need for any specialist equipment, including housing adaptations, with relevant professionals;
• ensure any essential specialist equipment is in place at the point of discharge; and
• agree the plan for continuing treatment and support with the community-based multidisciplinary team.

Background

12. Mr B’s late father, Mr G, suffered a stroke in September 2020. He went into hospital for an emergency procedure to remove a blood clot which caused the stroke. Following the procedure Mr G was admitted to the Hospital’s Trust Stroke Rehabilitation Unit.
13. The Hospital Trust fitted Mr G with a urinary catheter. It changed the catheter on 24 September and prescribed him with a course of oral antibiotics because of a suspected catheter associated urinary tract infection (UTI).
14. The Hospital Trust sent a referral to the Council so it could arrange homecare support once Mr G was medically fit for discharge from hospital. The Council said it was part of the multidisciplinary team which dealt with the discharge. The Council started to look for reablement support at the end of September. The Council did not complete an assessment or care and support plan but acted on the information in the Discharge to Assess form which stated Mr G’s needs and goals.
15. Mr G was discharged home from hospital on 8 October as the Hospital Trust had assessed him medically fit for discharge. He received a care package consisting of one carer providing 30 minutes three times daily. He was discharged with a catheter fitted by the Hospital Trust. The social care support requested by the Council for Mr G included assistance with mobilising around the house, help with meal preparation, toileting and taking medication.
16. A nurse from the Community Trust spoke to Mr G’s daughter by telephone on
    9 October who said she suspected her father had a urine infection. The nurse provided Mr G’s daughter with a contact number for the out-of-hours service.
    Mrs G left a message later that day asking someone from the Community Nursing Team to discuss Mr G’s catheter with the care agency later that afternoon.
17. A physiotherapist visited Mr G the same day and discovered his catheter had been pulled out (by Mr G). The physiotherapist contacted the Community Nursing Team by telephone to discuss the issue. A community nurse told the physiotherapist the team wanted to allow time for Mr G to recover due to ‘traumatic self-removal of catheter.’ The community nurse advised the physiotherapist to monitor the situation and report any concerns. The community nurse reported the situation to the out-of-hours nursing service to make them aware.
18. A community nurse telephoned Mrs G on 10 October following a referral from the NHS 111. The notes refer to Mrs G telling the nurse her husband had improved cognitively and he would not want a catheter reinserted.
19. A community nurse visited the next day and identified a possible urine infection. The nurse referred the matter to Mr G’s general practitioner (GP) who then arranged to visit the same day. The GP prescribed antibiotics for the urine infection and medication for anxiety.
20. A community nurse visited Mr G again on 14 October. Mrs G confirmed that Mr G had a Conveen catheter (an external urinary catheter which is non-invasive) fitted and was continuing with antibiotics. The community nursing notes state ‘will call next week to review’.
21. Mr G was readmitted to hospital on 19 October following a fall secondary to a suspected UTI. The Hospital Trust started antibiotics to treat the suspected UTI and Mr G showed signs of improvement by 26 October.
22. Mr B said he was told a patient in the same hospital bay as his father had tested positive for coronavirus. He said his father then tested positive for coronavirus on 30 October. However, he said his father remained stable for a period but then deteriorated. The Hospital Trust said a chest x-ray confirmed lung inflammation and it continued with antibiotics and intravenous fluids.
23. The Hospital Trust said by 12 November Mr G’s blood tests showed he had worsening kidney function and an examination showed he had a palpable bladder. In response it inserted a new catheter as clinicians felt deterioration in kidney function could be related to an obstruction from the bladder.
24. Mrs G said she was told Mr G was nearing the end of his life on 16 November and Mr B said this was a shock. Mr B said he visited his father on 18 November and was surprised to see him on the same ward as he felt he should have been isolated on a Covid ward. Mr G continued to deteriorate, and he died on 26 November in hospital.

Findings

Mr G’s discharge from hospital

25. Mr G’s primary reason for admission to hospital was because of the stroke he had suffered. During the weeks he spent in hospital he developed a UTI and at times exhibited signs of confusion.
26. Mr G’s clinical records show the treatment and clinical care he received leading up to his discharge from hospital. From September 2020 clinicians noted issues surrounding the catheter Mr G had fitted. This included times when he had removed the catheter due to his confusion.
27. The National Institute for Health Care Excellence (NICE) has published clinical guidance [CG162] which refers to stroke rehabilitation in adults. This encourages early supported discharge when possible. In this case the Hospital Trust’s clinicians assessed Mr G over time and the clinical records show improvement in his health while he was in hospital which then allowed clinicians to consider his discharge arrangements.
28. The clinical records show that Mr G received antibiotics to treat the UTI and the evidence available suggests this had beneficial effect. On the evidence available now, it is more likely than not Mr G did not have a UTI when the Hospital Trust discharged him from hospital. He was clinically stable and was ready to be discharged home with support with a plan to assess his long-term needs.
29. Timely discharge is when a patient is discharged home or transferred to an appropriate level of care as soon as they are clinically stable and fit for discharge. Mr G was fit for discharge and had reached the point where his health and social care needs could be met in the community with appropriate support in place. Although Mr B complained the Hospital Trust should not have discharged his father home when it did, I have not seen any evidence to suggest there was fault in the way the Hospital Trust made its decision to discharge Mr G.
30. The Hospital Trust started discharge planning in good time and as part of the multi-disciplinary team it referred Mr G to the Council so it could arrange social care support for when he returned home. Although the Hospital Trust ensured
    Mr G was referred for social care support it accepted it did not include a referral to the community nursing team as part of the discharge to assess process. This is fault.
31. Prior to Mr G’s discharge from hospital the clinical records document occasions when he had removed the catheter nursing staff had inserted (self twoc). As he was in hospital nursing staff were able to replace the catheter after seeking
    Mr G’s consent to do so. This should have alerted the Hospital Trust to the importance of the referral to the community nursing team. It should have also highlighted this information in the referral it sent to the Council.
32. The Council did not complete a full assessment of Mr G’s needs in line with the Care Act 2014. Due to the nature of discharge to assess it would ordinarily complete a full review of Mr G’s longer term needs after a period of recovery in the community.
33. The hospital discharge guidance which was in place at the time said, ‘information about the home circumstances for people should have been collected at the point of admission. If further home assessment is required this should be undertaken in good time, coordinated between health and social care and should include equipment and reablement support. Trusted assessment arrangements should be used.’
34. Trusted assessment arrangements can vary but the purpose is to prevent unnecessary delays in hospital discharges. In response to our enquiries the Council said it was working within the COVID hospital discharge guidance relevant at the time. It confirmed the Dorset model meant it was not undertaking assessments in hospital. Instead, wards made a trusted assessment via a discharge to assess referral. The Council said it would then commission care using the referral under COVID funding. It would then later complete a Care Act assessment in the community once the person had been discharged.
35. The referral sent to the Single Point of Access (SPA) set out the reason for Mr G’s admission to hospital, a brief past medical history and what support Mr G would need on discharge. The referral noted that family would be responsible for care tasks alongside commissioned care noted as three times daily. Under night visit the referral is marked ‘no’. The referral form provided by the Council is blank in the section which refers to Case Manager overview and plan. This is fault.
36. The guidance in place at the time said Hospitals should transfer information ‘essential to the continued delivery of care and support’ to social care services on discharge. It also says, ‘health and care systems should ensure… full and documented assessments of need, to ensure care providers can deliver the care and support people require’.
37. There is no evidence to show how the Hospital Trust or the Council considered Mrs G’s willingness or ability to undertake the caring role as set out in the assessment. I have not seen evidence to show how Mr G was involved in the discharge to assess referral. There is no consideration of catheter care as already highlighted or evidence to show what was expected of the care provider regarding this. This is fault as I find both the Hospital Trust and the Council should have considered these issues when arranging care and support in the community. This fault is likely to have led to the issues with the care agency around catheter care awareness and this impact this had on Mrs G’s caring role.
38. While I appreciate the Council would have considered Mr G’s longer term care needs at a later date including Mrs G’s needs as a carer the discharge to assess model is not intended to replace the need for agreed multi professional assessments or detract from the requirement to ensure safe discharge.
39. The Council said the protocol in place at the time was to send a copy of the discharge to assess form to the care provider at the point of booking the care package. It is unclear what other information the Council provided to the care agency alongside the referral.

The care and support provided to Mr G in the community

40. The Community Trust’s records show Mrs G and her daughter had contacted the community nursing team about the catheter the day after Mr G’s discharge. Mrs G wanted a nurse to visit to meet the commissioned carers to discuss the catheter. Later the same day a physiotherapist also visited Mr G and contacted the community nursing team because Mr G had removed the catheter.
41. The physiotherapist had concerns about the commissioned carers as they did not seem to be aware of what was expected of them regarding the catheter. The physiotherapist also had concerns because the commissioned carers had not reported Mr G’s removal of the catheter to any other agency such as the community nursing team. These faults are likely to have been caused by the lack of consideration when the Hospital Trust and the Council dealt with Mr G’s discharge arrangements and commissioned the homecare.
42. The documentary evidence shows the community nursing team provided advice and the out of hours number to Mr G’s daughter, Mrs G and the physiotherapist. The advice included encouraging Mr G to drink fluids and monitoring the situation. The Community Trust also provided the number for its out of hours service and alerted them to the situation. This is evidence of good practice.
43. The Council received a call from the domiciliary care agency four days after
    Mr G’s discharge from hospital. The care agency had concerns around catheter care and questioned the support carers were supposed to be providing to Mr G. The Early Supported Discharge Team also contacted the Council following a visit to Mr G to say he was getting up between four and five times at night and he was at risk of falls. Referring to the effect this was having on Mrs G the records state she was ‘at breaking point with carer stress.’
44. When the Council’s officer spoke to Mrs G the record of the call refers to her being happy with the care during the day but states she had concerns about the night-time (limited support). She also said she felt assistive technology would help to manage Mr G getting out of bed at night and asked for a referral to be made.
45. The Hospital Trust and the Council should have properly considered Mr G’s immediate holistic needs as well as Mrs G’s needs as a carer when dealing with the discharge to assess. This information could have been used to personalise the care package the Council arranged with the domiciliary care agency. This would have also ensured the care agency was clear about the support required and who had responsibility for catheter care.
46. The evidence available suggests a lack of coordination between health and social care services. It is also likely to have led to a delay in considering Mr G’s night-time needs and Mrs G’s needs as his carer. This more than likely contributed to Mrs G experiencing increased carer’s strain as she and other agencies reported to the Council after the care package had started.
47. The day after the catheter had been removed Mrs G confirmed to the community nursing out of hours team Mr G would not want another catheter reinserted. Therefore, the community nursing team monitored the situation and referred Mr G to his GP for review when it was suspected he might have a UTI. The GP prescribed medication for the infection and did not think it necessary to take further action. There is no evidence to suggest the Community Trust did not act in line with established good practice and therefore I cannot say it is at fault.

The Hospital Trust’s Prevention and Control of Infection

48. Mr G was readmitted to hospital on 19 October 2020 as he had fallen due to a suspected UTI. The clinical records on the admission date show a Covid-19 swab was taken at the time and this showed no evidence of infection. The Hospital Trust tested again a few days later and there was no evidence of infection.
49. When responding to Mr B’s complaint the Hospital Trust said on 23 October a routine test detected coronavirus in a patient who was sharing a bay with Mr G. Around this date Mr G was still testing negative and remained on the ward although the patient who tested positive was moved to a dedicated Covid-19 isolation ward to help control the spread of infection.
50. Further testing by the Hospital Trust showed Mr G had tested positive on or around 30 October. The Hospital Trust did not have a local policy for infection control in place but followed the national guidance in place at the time.
51. The Hospital Trust decided not to move Mr G to a different ward when he tested positive because cases had spread across the word. This meant the ward Mr G was on became a Covid-19 isolation ward. The guidance in place at the time focussed on minimising the spread of infection. By the time Mr G tested positive he did not have to be moved. I have not found fault in the way the Hospital Trust made the decision.
52. I have not seen evidence to show the Hospital Trust placed Mr G on a ward where patients had already tested positive for the virus known as Covid-19 as
    Mr B claimed. The Hospital Trust was following national guidance and needed to ensure it put measures in place so its wards, where practicable, were COVID-secure. I have not seen evidence to suggest the Hospital Trust acted with fault in relation to this part of the complaint.

Conclusion

53. The evidence available supports the view the Hospital Trust worked with the Council to ensure a timely discharge from hospital when Mr G was assessed as clinically stable. The Hospital Trust did not refer Mr G to the Community Trust when it should have done, and this was fault. However, any injustice caused to
    Mr G was limited due to the short delay in the Community Trust being alerted to Mr G’s case. The Hospital Trust apologised and reminded key staff about the importance of referrals to community hospital services before the Ombudsmen considered this complaint. It is not necessary to make a further recommendation.
54. I have not seen evidence to show the Hospital Trust and the Council completed the discharge to assess form in line with the guidance in place at the time. This led to a lack of coordination between health and social care services. There was a delay to properly consider the impact Mr G’s discharge and the support recommended would have on his carer, Mrs G. This is likely to cause Mr B and Mrs G to have uncertainty about the care and support provided to Mr G. It is also likely Mrs G experienced increased carer’s strain because of the faults identified.
55. The guidance relating to hospital discharge has changed since the events occurred during the period complained about. The Council confirmed its process for hospital discharge is different now. For this reason, it is not necessary to recommend a service improvement.
56. I have not found evidence of fault with the actions of the Community Trust and the evidence available suggests it responded appropriately to provide advice and refer Mr G to his GP for review when it suspected he had an infection. It could not provide direct catheter care as this had been removed by the time it became involved.

Back to top

Agreed recommendations

57. The Council and the Hospital Trust have agreed to our recommendation and within one month of our final decision:
• the Council and the Hospital Trust will write to Mr B and Mrs G and apologise for the uncertainty they experienced because of the faults identified.
• the Council and the Hospital Trust will also apologise to Mrs G for the increased carer’s strain she experienced and pay her £500 (£250 each) to acknowledge the impact the faults had on her.
58. The organisation will provide us with evidence it has complied with the above actions.

Back to top

Final decision

59. I uphold Mr B’s complaint about the way the Council and the Hospital Trust dealt with his late father’s discharge from hospital. I do not uphold Mr B’s complaint about the decision to discharge and the prevention and control of infection. The Council and the Hospital Trust have agreed to our recommendations. I have completed the investigation.

Back to top

Investigator's decision on behalf of the Ombudsman